Ultrasound-Guided Perimeniscal Injections: Anatomical Description and Feasibility Study.

OBJECTIVES: To anatomically describe the ultrasound (US)-guided perimeniscal injection technique, and evaluate its feasibility in the treatment of meniscal pain. METHODS: This work was initially undertaken in four cadaveric specimens with US-guided medial and lateral perimeniscal injection of China ink, followed by cadaveric dissection to assess injectate distribution, and potential injury to intra-articular and peri-articular structures. Then, 35 consecutive patients who underwent US-guided perimeniscal corticosteroid injection under local anesthesia for the treatment of symptomatic medial (30/35) or lateral (5/35) degenerative meniscal tear were retrospectively evaluated. Clinical outcome was assessed using a 0-10 numerical verbal rating scale (VRS) to evaluate severity of pain before, during, and after procedure at 6 weeks follow-up. RESULTS: Seven of eight (87.5%) ex vivo injections were accurate. A single inaccurate medial perimeniscal injection infiltrated the tibial collateral ligament instead of the perimeniscal area. No anatomical specimen exhibited intrameniscal injection or injury to regional structures. All procedures (35/35) performed clinically were technically successful. Median VRS scores were: 7 (range, 3-9) before procedure, 5 (range, 0-10) during procedure, and 1.5 (range, 0-9) after procedure at 6 weeks follow-up (P <.0001). No complication was observed. CONCLUSIONS: US-guided perimeniscal injections can accurately and safely deliver injectates in the perimeniscal area. In addition, our data suggest that perimeniscal corticosteroid injection provides significant symptom relief at 6 weeks in patients with meniscal pain. Further studies with long-term follow-up will be required to evaluate the role of perimeniscal injections in the nonoperative management of meniscal pathology.

Poststroke Postural Sway Improved by Botulinum Toxin: A Multicenter Randomized Double-blind Controlled Trial.

OBJECTIVE: To assess the effects of injecting botulinum toxin into the lower limb muscles of people with hemiparesis post stroke in terms of their sway areas. DESIGN: A multicenter randomized double-blind trial on the effects of active botulinum toxin treatment vs placebo. SETTING: Clinical examinations and postural sway assessments were performed before botulinum toxin injection and again 4-6 weeks after the injection. PARTICIPANTS: People with hemiparesis with chronic post stroke lower limb spasticity (N=40). INTERVENTIONS: Intramuscular injection of a placebo (physiological serum) was performed on the control group, and botulinum toxin injections were performed on the treatment group. Participants and physical and rehabilitation medicine specialists were given no information as to which of the 2 treatments was applied. MAIN OUTCOME MEASURES: The sway area of the center of pressure was recorded for 30 seconds in 3 conditions: eyes open, eyes open in a dual task (a postural control task combined with an arithmetic task), and eyes closed. Spasticity was measured using the Modified Ashworth Scale. RESULTS: Forty people post stroke were enrolled and randomized into 2 groups, one of which was treated with botulinum toxin (n=19) and the other with placebo (n=21). Spasticity decreased significantly in the treatment group (-0.7, P=.049 in the soleus muscles; -0.8, P=.035 in the gastrocnemii muscles). The sway area did not differ significantly between the 2 groups before treatment. The most conspicuous effect was observed in the case of the dual task, where a significant decrease (P=.005) in the sway area occurred in the treatment group (-3.11±6.92) in comparison with the placebo group (+0.27±3.57). CONCLUSION: Treating spasticity by injecting botulinum toxin into people's lower limb muscles post stroke seems to improve their postural sway. The dual task used here to assess sway seems to be a useful, sensitive test for this purpose.

Intensive Early Rehabilitation in the Intensive Care Unit for Liver Transplant Recipients: A Randomized Controlled Trial.

OBJECTIVE: To validate the feasibility and tolerance of an intensive rehabilitation protocol initiated during the postoperative period in an intensive care unit (ICU) in liver transplant recipients. DESIGN: Prospective randomized study. SETTING: ICU. PARTICIPANTS: Liver transplant recipients over a period of 1 year (N=40). INTERVENTIONS: The "usual treatment group" (n=20), which benefited from the usual treatment applied in the ICU (based on physician prescription for the physiotherapist, with one session a day), and the experimental group (n=20), which followed a protocol of early and intensive rehabilitation (based on a written protocol validated by physicians and an evaluation by physiotherapist, with 2 sessions a day), were compared. MAIN OUTCOME MEASURES: Our primary aims were tolerance, assessed from the number of adverse events during rehabilitation sessions, and feasibility, assessed from the number of sessions discontinued. RESULTS: The results revealed a small percentage of adverse events (1.5% in the usual treatment group vs 1.06% in the experimental group) that were considered to be of low intensity. Patients in the experimental group sat on the edge of their beds sooner (2.6 vs 9.7d; P=.048) and their intestinal transit resumed earlier (5.6 vs 3.7d; P=.015) than patients in the usual treatment group. There was no significant difference between the 2 arms regarding length of stay (LOS), despite a decrease in duration in the experimental group. CONCLUSIONS: The introduction of an intensive early rehabilitation program for liver transplant recipients was well tolerated and feasible in the ICU. We noted that the different activities proposed were introduced sooner in the experimental group. Moreover, there is a tendency to decreased LOS in the ICU for the experimental group. These results now need to be confirmed by studies on a larger scale.

Robotic gait training and botulinum toxin injection improve gait in the chronic post-stroke phase: A randomized controlled trial.

BACKGROUND: Improving walking ability is one of the main goals of rehabilitation after stroke. When lower limb spasticity increases walking difficulty, botulinum toxin type A (BTx-A) injections can be combined with non-pharmacologic interventions such as intensive rehabilitation using a robotic approach. To the best of our knowledge, no comparisons have been made between the efficacy of robotic gait training and conventional physical therapy in combination with BTx-A injections. OBJECTIVE: To conduct a randomized controlled trial to compare the efficacy on gait of robotic gait training versus conventional physiotherapy after BTx-A injection into the spastic triceps surae in people after stroke. METHOD: Thirty-three participants in the chronic stroke phase with triceps surae spasticity inducing gait impairment were included. After BTx-A injection, participants were randomized into 2 groups. Group A underwent robotic gait training (Lokomat®) for 2 weeks, followed by conventional physiotherapy for 2 weeks (n = 15) and Group B underwent the same treatment in reverse order (n = 18). The efficacy of these methods was tested using the 6-minute walk test (6MWT), comparing post-test 1 and post-test 2 with the pre-test. RESULTS: After the first period, the 6MWT increased significantly more in Group A than in Group B: the mean difference between the interventions was 33 m (95%CI 9; 58 p = 0.007; g = 0.95), in favor of Group A; after the second period, the 6MWT increased in both groups, but the 30 m difference between the groups still remained (95%CI 5; 55 p = 0.019; g = 0.73). CONCLUSION: Two weeks of robotic gait training performed 2 weeks after BTx-A injections improved walking performance more than conventional physiotherapy. Large-scale studies are now required on the timing of robotic rehabilitation after BTx-A injection.

Fitness and walking outcomes following aerobic and lower extremity strength training in facioscapulohumeral dystrophy: a case series.

Facioscapulohumeral muscular dystrophy (FSHD) is a common form of adult muscular dystrophy often resulting also in cardiorespiratory deconditioning and weakness of the lower limbs. Although previous studies examined outcomes of interventions aimed at improving either cardiorespiratory fitness or muscle strength, the potential benefits of a rehabilitation program targeting both remain unexplored. Thus, the aim of this study was to evaluate changes following participation in a rehabilitation program combining aerobic and strength exercises. We conducted a retrospective analysis of 10 subjects with FSHD who participated in our rehabilitation program during 2018 and 2019. Each of the 20 sessions consisted of aerobic training on a cycloergometer and a moderate lower limb strength exercises on an isokinetic machine in combination with conventional therapy. The primary outcomes were walking speed, aerobic performance and isokinetic strength of the knee extensors and flexors. The secondary outcomes were fatigue, insomnia. VO2max and walking speed increased significantly by 2.125 ml·kg-1·min-1 [95% confidence interval (CI): 0.75-3.62, P = 0.022] and 0.28 m/s (95% CI: 0.16-0.4, P = 0.002), respectively. The effect size was small for V02max (Hedge's g, 0.44; 95% CI: -0.5 to 1.37) and large for walking speed (Hedge's g, 0.99; 95% CI: 0.06-1.92). The knee flexor strength significantly increased at rehabilitation discharge (repeated measures analysis of variance P = 0.004). Positive changes in fatigue and insomnia were also observed. Our preliminary results provide evidence that a relatively short course of a comprehensive rehabilitation program targeting both cardiorespiratory fitness and knee muscle strength can be beneficial for people with FSHD, which warrants further prospective studies.

Prosthesis for bilateral equinus foot: A case study.

BACKGROUND: Although surgical treatment for equinus foot has been widely described in the literature, less attention has been paid to orthopedic treatment with prostheses, which constitutes an interesting alternative approach. It has been described in the literature for treating lower-limb inequality, but not for equinus foot. The aim of this article is to report that the use of prosthetics can be a valid means of managing bilateral equinus foot. CASE DESCRIPTION AND METHODS: In the present case report, we describe the management of an irreducible bilateral equinus in a 45-year-old patient with poliomyelitis sequelae, starting with orthoses and orthopedic shoes, followed by prostheses. We measured the evolution of the patient's spatiotemporal gait parameters, his autonomy, and his satisfaction with a QUEST score. FINDINGS AND OUTCOMES: Despite the deterioration of the patient's physical abilities due to the onset of a postpoliomyelitis syndrome, his gait parameters and his autonomy were maintained while using the prostheses. His tolerance of the prostheses improved even more greatly, as shown by his QUEST score, which increased from 2.95 to 4.67 of 5. CONCLUSION: The use of prostheses was at least as effective and even better tolerated than orthoses and orthopedic shoes by this patient. Despite the occurrence of a postpoliomyelitis syndrome, the prostheses helped to maintain his walking performances, while improving his satisfaction.

Use of his prostheses by a double upper limb amputee 6 years after amputation: From aesthetic to functional considerations, a case report.

BACKGROUND: Few studies have been published on the prosthetic management of bilateral upper limb amputees. Of particular interest is to study how a patient's use of his upper limb protheses had evolved over a 6-year period in the aim to decrease their rejection rate. CASE DESCRIPTION AND METHODS: Mr. D had undergone a bilateral upper limb amputation and had been fitted with 7 different prostheses in the past 6 years. Multiple validate instruments and analyses were then used to monitor the patient's fitting and choices. FINDINGS AND OUTCOMES: Initially, the left prosthesis was regarded as the dominant hand and the right one as the assistive power grip hand. However, the observational results showed that wearing only a left Greifer enabled the prosthetic user to perform the same tasks as with 2 prostheses. He has gained greater satisfaction and quality of life without losing his independence. CONCLUSION: The patient seemed to make a functional choice over his worrying about his physical appearance in favor of the efficiency of his prosthesis, which was essential for his everyday life, when he decided to wear only nonanthropomorphic prosthesis.

Riluzole for treating spasticity in patients with chronic traumatic spinal cord injury: Study protocol in the phase ib/iib adaptive multicenter randomized controlled RILUSCI trial.

BACKGROUND: Satisfactory treatment is often lacking for spasticity, a highly prevalent motor disorder in patients with spinal cord injury (SCI). Low concentrations of riluzole potently reduce the persistent sodium current, the post-SCI increase in which contributes to spasticity. The repurposing of this drug may therefore constitute a useful potential therapeutic option for relieving SCI patients suffering from chronic traumatic spasticity. OBJECTIVE: RILUSCI is a phase 1b-2b trial designed to assess whether riluzole is a safe and biologically effective means of managing spasticity in adult patients with traumatic chronic SCI. METHODS: In this multicenter double-blind trial, adults (aged 18-65 years) suffering from spasticity after SCI (target enrollment: 90 participants) will be randomly assigned to be given either a placebo or a recommended daily oral dose of riluzole for two weeks. The latter dose will be previously determined in phase 1b of the study by performing double-blind dose-finding tests using a Bayesian continuous reassessment method. The primary endpoint of the trial will be an improvement in the Modified Ashworth Score (MAS) or the Numerical Rating Score (NRS) quantifying spasticity. The secondary outcomes will be based on the safety and pharmacokinetics of riluzole as well as its impact on muscle spasms, pain, bladder dysfunction and quality of life. Analyses will be performed before, during and after the treatment and the placebo-controlled period. CONCLUSION: To the best of our knowledge, this clinical trial will be the first to document the safety and efficacy of riluzole as a means of reducing spasticity in patients with chronic SCI. TRIAL REGISTRATION: The clinical trial, which is already in progress, was registered on the ClinicalTrials.gov website on August 9, 2016 under the registration number NCT02859792. TRIAL SPONSOR: Assistance Publique-Hôpitaux de Marseille.

Innovative Therapy Combining Neck Muscle Vibration and Transcranial Direct Current Stimulation in Association with Conventional Rehabilitation in Left Unilateral Spatial Neglect Patients: HEMISTIM Protocol for a Randomized Controlled Trial.

Unilateral spatial neglect (USN) rehabilitation requires the development of new methods that can be easily integrated into conventional practice. The aim of the HEMISTIM protocol is to assess immediate and long-term recovery induced by an innovative association of left-side neck-muscle vibration (NMV) and anodal transcranial Direct Current Stimulation (tDCS) on the ipsilesional posterior parietal cortex during occupational therapy sessions in patients with left USN. Participants will be randomly assigned to four groups: control, Left-NMV, Left-NMV + sham-tDCS or Left-NMV + anodal-tDCS. NMV and tDCS will be applied during the first 15 min of occupational therapy sessions, three days a week for three weeks. USN will be assessed at baseline, just at the end of the first experimental session, after the first and third weeks of the protocol and three weeks after its ending. Our primary outcome will be the evolution of the functional Catherine Bergego Scale score. Secondary outcome measures include five tests that investigate different neuropsychological aspects of USN. Left NMV, by activating multisensory integration neuronal networks, might enhance effects obtained by conventional therapy since post-effects were shown when it was combined with upper limb movements. We expect to reinforce lasting intermodal recalibration through LTP-like plasticity induced by anodal tDCS.

Awakening the control of the ankle dorsiflexors in the post-stroke hemiplegic subject to improve walking activity and social participation: the WAKE (Walking Ankle isoKinetic Exercise) randomised, controlled trial.

BACKGROUND: Stroke is the leading cause of acquired disability in France. While 90% of patients recover the ability to walk, it is often limited with a steady speed of approximately 0.7 m/s. This limitation of walking activity is partly related to a decrease in strength associated with more or less significant spasticity. In particular, it seems that the strength of the dorsiflexor muscles is directly related to walking speed. We hypothesise that a protocol based on gestural repetition targeted at the ankle during the subacute phase potentiates the recovery of motor control, improving walking activity, and participates in recovering better social participation. METHODS: An estimated total of 60 patients with subacute stroke will be recruited to participate in this multicentre, interventional, prospective, randomised controlled trial. All participants will benefit from conventional rehabilitation. In addition, the experimental group will take part in an ankle isokinetic rehabilitation programme for 6 weeks (at least 25 sessions). The control group will receive the same duration of conventional rehabilitation. The primary outcome measure will be a 10-m walking speed at post-intervention. Secondary outcomes will include social participation, walking spatio-temporal parameters, and dorsiflexor strength. Outcome measurements will be taken at baseline, immediately after treatment (6 weeks), then at 6 months and 1 year of follow-up. DISCUSSION: This study aims to provide scientific evidence that a protocol based on an early over-solicitation of the ankle dorsiflexor muscles to promote their "awakening" can serve to achieve a more effective walking activity, which in turn encourages social participation following discharge from the hospital. This protocol should also help optimise physical medicine and rehabilitation practices: the more systematic use of the isokinetic dynamometer as a technique associated with, and integrated into the conventional rehabilitation protocol would allow an objective evaluation of the rehabilitation benefits and should increase the rehabilitation gain in central nervous system disorders. TRIAL REGISTRATION: Limoges University Hospital is the sponsor of this research (Unique Protocol ID: 87RI18_0010) This research is supported by the French Ministry of Health (PHRC 2020-A03328-31) and is conducted with the support of DGOS (PHRC interregional - GIRCI SOHO). The study protocol was approved by the French Human Subjects Protection Review Board (Comité de Protection des Personnes Nord-Ouest III) on February 23, 2021. The trial was registered in the ClinicalTrials.gov registry ( NCT04800601 ) on March 16, 2021.

Evaluation of patients with gait abnormalities in physical and rehabilitation medicine settings.

The first step in the assessment of patients with gait abnormalities in physical and rehabilitation medicine settings is a clinical examination based on the International Classification of Functioning, Disabilities and Health. Body structure, activities and participation, and environmental factors (physical and human factors) must all be assessed. Qualitative and quantified assessments of gait are part of the activity and participation evaluation. Scales are also used to assess gait activities. Gait assessment tools can be used in laboratory environments for kinematic, kinetic, electromyographic and energy consumption analysis and other tools, such as videotape and walkways, can be used in clinical practice, while ambulatory assessment tools can be used to analyse patients' usual everyday activities. The aims of instrumental gait assessment are: to understand the underlying mechanisms and the aetiology of the disorders, to obtain quantified gait parameters, to define suitable therapeutic methods, and to follow the course of the disease.

Knee-ankle-foot orthoses for treating posterior knee pain resulting from genu recurvatum: Efficiency, patients' tolerance and satisfaction.

OBJECTIVE: To assess the efficiency of knee-ankle-foot orthoses for treating painful genu recurvatum, and to determine users' tolerance and satisfaction. PATIENTS: Patients included in the study had a genu recurvatum during the stance phase, confirmed by a medical doctor on physical examination. A total of 27 patients with 31 knee-ankle-foot orthoses were included. METHODS: The main outcome was scored on a verbal numerical rating scale (VNRS) before and at least 3 months after a knee-ankle-foot orthosis was fitted, and scored on a verbal numerical pain rating scale (VRS). Secondary outcomes were rated with the Quebec User Evaluation of Satisfaction with assistive Technology (QUEST). RESULTS: After fitting the knee-ankle-foot orthosis, the median VNRS pain score decreased from 85/100 to 25/100 (p ≤ 0.001) and the description of pain on the VRS decreased from "extreme" to "mild" (p ≤ 0.001). The QUEST total score was 4.0. CONCLUSION: Treating a painful genu recurvatum with a knee-ankle-foot orthosis reduced the pain efficiently whatever the patients' diagnosis, and high scores were obtained for patients' satisfaction.

Return to surfing using an adapted prosthesis: A case report.

BACKGROUND: Surfing with transfemoral knee prosthesis requires flexion of the hip, knee, and ankle and balance between flexibility and stiffness of the prosthetic limb. We report on Mr D, a transfemoral amputee, who wanted to surf again. Case Description and Methods: Technical specifications were based on Mr D's complaint. The prosthesis is salt water resistant and combines a shock absorber associated with elastic tendons to permit the knee to bend easily and to facilitate eccentric braking. Surfing was observed using videos of movements and subjective analysis of compensations. Findings and Outcomes: Mr D uses this prosthesis for surfing with good results and got back to his former level using compensations. During the takeoff, he cannot shorten his left leg. He makes a circumduction movement to put his leg in front of the board. CONCLUSION: This prosthesis is adapted for surfing and allows precise adjustments to surfing conditions. Clinical relevance Appropriate prosthesis design can enable return to surfing for a transfemoral amputee.

Gait recovery in a distal spinal muscular atrophy patient wearing a patellar tendon-bearing orthosis and orthopaedic shoes.

OBJECTIVE: To illustrate that a patient with distal spinal muscular atrophy can recover gait with a combination of orthoses and orthopaedic shoes. SUBJECT: A 28-year-old man with distal spinal muscular atrophy affecting only the distal muscles of the lower limbs. Clinical examination showed a bilateral pes cavus with a varus and a 90 degrees equinus of the ankle joint. METHODS: The patient was fitted with orthopaedic shoes and a patellar tendon-bearing orthosis. In order to assess the clinical effects of this fitting, a complete physical examination was performed and the patient's temporo-spatial gait parameters were assessed quantitatively using gait analysis tools (Gaitrite) both prior to treatment and after one month. RESULTS: Before the fitting, the patient was not able to walk alone or to maintain an upright position and he suffered from foot pain. One month after the fitting was applied, the patient was able to walk alone and to maintain an upright position for 1 hour. His pain disappeared. Quantified study of the patient's gait parameters shows that the temporo-spatial parameters are close to normal with fitting. CONCLUSION: Clinical and quantitative data both confirm the subjective improvements reported by the patient.

Kinematic and kinetic asymmetries in hemiplegic patients' gait initiation patterns.

OBJECTIVE: To assess the kinetic and kinematic characteristics of hemiplegic stroke patients' gait initiation patterns during the various gait initiation phases. DESIGN AND SUBJECTS: Gait initiation was studied in 3 hemiplegic subjects with a spastic equinus varus foot and 3 control subjects. METHODS: Temporal and kinetic analysis of gait initiation was performed with 2 AMTI force plates, and kinematic analysis of gait initiation with an ELITE optoelectronic system. A one-way ANOVA was performed directly on the phase durations, forces, centre of pressure displacements, stride length, and ankle motion range. RESULTS: Duration of the monopodal phase was shorter in hemiplegic patients when the affected leg rather than the sound one was used as the supporting leg. Propulsion forces were exerted by the hemiplegic patients' sound leg during the postural phase. Hemiplegic patients' body weight was supported more by the sound leg than by the affected leg. Knee was lifted higher on the affected side during the swing phase to compensate for the equinus. Initial contact was performed with a flat foot on the affected side. CONCLUSION: Quantitative data obtained on the gait initiation phase suggest that hemiplegic patients develop asymmetrical adaptive posturo-motor strategies to compensate for their impairments.

Does fascicular neurotomy have long-lasting effects?

OBJECTIVE: To determine whether fascicular neurotomy has long-lasting effects on spasticity. DESIGN: We present 4 clinical cases and a critical analysis of the literature. PATIENTS: This is a retrospective study on 4 patients referred to our department for spastic equinovarus foot deformity. For all 4, neurotomy was successful not long after surgery, but spasticity reappeared after a few months. METHODS: We compared our results with those in the PubMed database. RESULTS: Most publications acknowledge the immediate effectiveness of this surgery, but do not study the long-term effects of neurotomy. No publication proved long-lasting effects of neurotomy for spastic equinovarus foot deformity. The only long-term follow-up with a sufficient population is the one of Berard et al. who reported 61% recurrence. CONCLUSION: There is no study showing that tibial nerve neurotomy has long-lasting effects. The 4 cases reported are an illustration that recurrence of spasticity may occur after neurotomy. These findings have to be taken into account for treatment decision-making and for provision of information to patients.

Orthopaedic shoes along with physical therapy was effective in Charcot-Marie-Tooth patient over 10 years.

BACKGROUND: The aim was to investigate the effectiveness of custom-made orthopaedic shoes (derby shoes) along with physiotherapy (twice a week) on a person with Charcot-Marie-Tooth over a period of 10 years. CASE DESCRIPTION AND METHODS: A 66-year-old woman with Charcot-Marie-Tooth disease, who did not have other health conditions, complained of pain and frequent falls. Physical examination, including ankle, knee and hip muscle strength; sensory evaluation of foot and joint range of motion; self-reported assessment of pain, frequency of falls and sprains; and gait analyses, including spatial and temporal parameters and motion analyses, were performed in 2001, 2007 and 2011. FINDINGS AND OUTCOMES: During the 10 years of follow-up, the physical examination parameters had stabilized since 2001; falls, sprains and walking distance had improved as compared to 2000; pain had alleviated since 2001 and gait parameters had improved up to 2007 and stabilized between 2007 and 2011. CONCLUSION: Bracing with orthopaedic shoes along with physical therapy was effective in treating pain, improving the gait and enhancing the walking distance (>500 m) without assistive device in a person with Charcot-Marie-Tooth disease. CLINICAL RELEVANCE: Orthopaedic shoes along with physical therapy can be a good option for treating Charcot-Marie-Tooth associated pain, foot drop, falls and sprains, improving the gait abnormalities and also increasing the walking distance.